I am a 69-year-old woman in good health. The large medical practice I have been going to for more years than I can count is struggling to recruit and retain primary-care doctors and is short-staffed in general. Wait times for appointments have grown longer, the nurse practitioner I’ve seen most regularly will be retiring soon and I just don’t feel confident that I will receive the attention and care I will want, if and when my health takes a turn. No one at the practice besides this nurse even knows me.
I recently learned of an internist and geriatric-care specialist who has opened a practice in my community. She has an excellent reputation and sounds like everything I could hope for in a doctor, especially at this stage of my life.
The catch is that although she accepts my health insurance, she charges an annual membership fee in order to keep the practice small, which in turn allows her to provide personal, timely care. I am fortunate in that I can afford the membership fee, but I am torn about the ethics of being part of this growing concierge-medicine trend. On the one hand, it obviously excludes most people, and it further strains the larger clinics (like the one I want to leave) as they try to absorb the patients whose doctors are adopting the concierge model. On the other hand, settling for care I don’t fully trust in order to stand on principle will do nothing to fix the horribly broken health care system in our country, and going with the new doctor could bring me great peace of mind.
What is the right thing to do? — Name Withheld, Massachusetts
From the Ethicist:
What you’re contemplating would have substantial benefits for you and a negligible effect on others. One fewer patient won’t affect a big clinic’s financials; if it had any marginal impact on the other patients, it might be in slightly reducing their wait times. So let’s think through your concern: that you’re participating in a harmful process that, at scale, leaves many people excluded from the better care and relegated to diminished services.
With respect to exclusion: Plenty of goods in our society are available only to the minority that can afford them — not just obvious luxuries (skiing vacations, opera tickets, pearl necklaces) but also fancier versions of necessities like food and housing. Many people couldn’t afford the home where you live or the restaurants where you dine. But buying your house didn’t make anyone homeless, and those meals don’t take food off anyone’s table. The general idea is that, as long as everyone’s getting what they’re entitled to, it’s OK to distribute other goods by price.
What about the effects of your getting superior medical care? You may think, as I do, that our society fails to guarantee everyone the level of medical care they should receive. And medical practices, not just yours, do struggle to find and hold onto primary-care physicians. Among the reasons: Medicare, which effectively anchors compensation levels throughout the health-care system, reimburses physicians according to “relative value units,” and those are largely determined by an advisory committee dominated by specialists. Procedures are valued more than conversations. Although rule changes have recently narrowed the gap a bit, many primary-care clinics, to survive, make physicians see patients in rushed 15-minute slots, leaving them unable to deliver the level of care they’re trained to provide.
That comes at a cost not only to patients but also to physicians. In fact, there has been a discussion of “moral injury” among health-care providers, arising from their sense that institutional constraints have left them unable to care properly for their patients. A 2023 report found that a quarter of U.S. physicians were thinking about leaving clinical work altogether. The membership model may keep some of them in practice, which is something to factor into any assessment. Doctors like the gerontologist you mention aren’t greedy (nobody goes into gerontology for the money). A safe guess is that they’re getting off the hamster wheel because they want to do good medicine and provide the valuable cognitive care that our current system short-shrifts.
The point is that the growth of membership medicine should be viewed as a symptom, not the disease. The “broken system” you refer to is one that already devalues the time and attention you may need as an older adult. And because the consequences of an individual consumer’s specific choice are so hard to calculate, this is a problem best addressed on the level of public policy. If you do want to try to do something about it, get involved in the politics of health care, or at least bear it in mind when you vote.
Readers Respond
The previous question was from a reader who discovered her ex-lover had lied about his marriage being over, and wondered whether she should tell his wife about their affair. She wrote:
Last summer, I was dating a man in our weekender community outside New York City who seemed like a wonderful guy. A month after we became intimate, he told me that he was married but that he had been separated from his wife for a year. He explained that the reason he has not gotten a divorce is that she has cancer and is on his health insurance. … Eventually, I ended the relationship, because I started feeling I wasn’t getting the full story. When I mentioned our relationship to a friend who also knows him, I learned that my instincts were correct. Apparently, he is very much still with his wife, and she is healthy. I am so shocked by this. Should I contact his wife and let her know this is what he is doing and saying? Given that they are both journalists, I would think veracity would be a priority. — Name Withheld
In his response, the Ethicist noted:
Your anger is justified. But justified anger isn’t necessarily a good guide to justified action. If you want to tell his wife in order to wound him, you’re being driven by revenge, a sentiment that rarely improves the moral situation. Nor should you be spurred by guilt. He was the deceiver, not you. Let’s be clear: He forfeited any claim to your discretion when he lied to you so extensively. And if this is a pattern with him, sharing your experience among your mutual acquaintances could spare others the same pain. We can agree, too, that his wife is entitled to know the truth about her husband. But that doesn’t mean you are the one who should deliver it. … If she’s unaware of the episode, your disclosure could upend her life; if she already knows, this couple may have reached a truce. … The question for you is whether you want to remain entangled with this man by intervening directly in his marriage. You can’t make him honest, but you don’t have to let his dishonesty define your life.
(Reread the full question and answer here.)
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I disagree with the Ethicist’s take. People like this man rely on others’ unwillingness to engage in conflict in order to carry out these horrible and hurtful deeds. If there were an agreement between him and his wife, then he wouldn’t have lied. Hold him accountable and make his actions known while remaining safe. — Samantha
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This happened to me. My ex-husband’s former lover called me to expose his betrayal. I’m sure it was to assuage her guilt and to extract some revenge against him. As devastating as the revelations were to me, I am glad that I learned about my cheating husband. It gave me important information about someone I trusted and about my financial and physical health. I am now divorced and feel better living without someone who not only betrayed my trust, but didn’t have the courage to own it. — Shoey
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The Ethicist is spot on. What is to be gained by telling the wife of her husband’s deceit? I was in a similar spot and decided that keeping quiet was the better road to take in the long run, even if it was not satisfying in the moment. The letter writer should let it go, and she should be glad her instincts helped her dodge a more hurtful outcome. — Steve
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The letter writer had a relationship with this guy for some number of months and became intimate but, presumably, was never invited to his home or participated in his friend group. She knew he was married but carried on nonetheless. Sounds to me like she needs to worry less about her ex-boyfriend’s ethics and more about the ethical implications of her own willful ignorance. — Robert
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My first husband cheated on me. I would have loved it if someone had told me it was happening so I could have the choice to “upend” my life sooner, rather than continue to live a lie and risk the S.T.I.s and financial shenanigans he could inflict upon me. If that doesn’t persuade the writer, perhaps putting herself in the wife’s shoes and asking whether she’d like to know would help. As it turned out, upending my life has turned out marvelously for me, and I’m much happier now. — Kathy
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